Iatrogenic Conchal Defect Secondary to Auricular Cartilage Graft.

BACKGROUND: Cleft lip and palate are the most common craniofacial congenital malformations. Timing of the nasal repair remains somewhat controversial. Some authors perform a combined nasal and lip repair in infancy while others advocate for a staged repair with the nasal component occurring later in childhood. Frequently, secondary repair is needed to address residual nasal deformities in early adulthood. Conchal cartilage has become increasingly popular as a source of cartilage for secondary reconstruction. Donor site morbidities include hematoma formation, scar formation, and wound healing complications. To the best of the authors' knowledge, there is 1 previous report of a full through-and-through conchal defect as a complication of auricular cartilage graft harvesting. The authors report an infrequently described iatrogenic conchal defect due to cartilage harvesting managed with a single-stage reconstruction using bookend flaps. METHODS: A 19-year-old female with a history of unilateral cleft lip and palate repair underwent secondary rhinoplasty using conchal cartilage. A bolster dressing was applied to the conchal harvest site. The patient was unable to attend her postoperative clinic visit and was eventually seen 2 months postoperatively with the bolster still in place. A full-thickness conchal defect was present when the bolster was removed. RESULTS: A pressure dressing such as a bolster is commonly used to prevent hematoma formation after conchal cartilage graft harvesting. This is routinely removed during the initial postoperative visit. Prolonged placement can result in donor site complications such as a full-thickness conchal defect. CONCLUSION: A functional and aesthetic reconstruction of a full-thickness iatrogenic conchal defect was achieved with excellent results using a local posterior flap, and 2 anteriorly based bookend flaps for closure. To the best of the authors' knowledge, this report is the first to describe a single-stage reconstruction of an iatrogenic defect in the concha as a complication of conchal cartilage harvesting.

Panniculectomy Outcomes in Patients with End-Stage Renal Disease in Preparation for Renal Transplant.

PURPOSE: End-stage renal disease (ESRD) is associated with increased cardiovascular risk factors, electrolyte imbalances, and iron deficiency anemia. These factors may increase the risk of adverse outcomes in patients undergoing panniculectomy. There is a paucity of data regarding outcomes in patients with ESRD undergoing panniculectomy. The purpose of this study is to investigate whether ESRD is associated with increased rate of complications following a panniculectomy. METHOD: The Nationwide Inpatient Sample database (2006-2011) was used to identify patients who underwent a panniculectomy. Among this cohort, patients diagnosed with end-stage renal disease were identified. Patients excluded from the study were emergency admissions, pregnant women, patients less than 18 years old, and patients with concurrent nephrectomy or kidney transplants. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-squared and risk-adjusted multivariate logistic regression analyses were performed to determine whether end-stage renal disease was associated with increased rate of postoperative complications. RESULTS: A total of 34,779 panniculectomies were performed during the study period. Of these, 613 (1.8%) were diagnosed with ESRD. Patients with ESRD were older (mean age 58.9 vs. 49.3, p < 0.01) and more likely to have Medicare (63.5 vs. 18.4%, p < 0.01). They had higher rates of comorbidities, including diabetes, hypertension, congestive heart failure, chronic lung disease, chronic anemia, liver disease, peripheral artery disease, obesity, and coagulopathies (p < 0.01). The procedure was more likely to occur at a large, teaching hospital (p < 0.01). Postoperatively, patients with ESRD had a higher rate of death (3.3 vs. 0.2%, p < 0.01), wound complications (10.6 vs. 6.2%, p < 0.01), venous thromboembolism (4.9 vs. 0.8%, p < 0.01), blood transfusions (25.3% vs. 7.0%, p < 0.01), non-renal major medical complications (40.0% vs. 8.4%), and longer hospital stay (9.2 vs. 3.8 days, p < 0.01). Multivariate logistic regression analysis controlling for age, race, sex, hospital location/teaching hospital, payer, and all comorbidities demonstrated that ESRD was independently associated with increased venous thromboembolisms (OR 2.38, 95% CI 1.48-3.83) and non-renal major medical complications (OR 1.51, 95% CI 1.19-1.91). ESRD was not independently associated with increased rate of wound complications or transfusions. CONCLUSION: Patients with ESRD are at increased risk of VTE and non-renal major medical complications following panniculectomy. Moreover, patients with ESRD have longer hospital stays and higher rates of mortality. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database.

BACKGROUND: Obesity may increase the risk of complications following abdominal contouring. The aim of this study is to evaluate panniculectomy outcomes in patients with class III obesity (BMI > 40 kg/m2). METHODS: The American College of Surgeon's National Surgical Quality Improvement Program ACS-NSQIP (2010-2014) was used to identify patients who underwent panniculectomy. Class III obesity patients were identified. Demographics, comorbidities and postoperative outcomes were evaluated. Risk-adjusted multivariate logistic regression analyses were performed to assess impact of class III obesity on panniculectomy outcomes. RESULTS: A total of 4497 panniculectomies were identified. Of these, 545 (12.1%) were performed in patients with class III obesity. This group was older (mean age 50.3 vs. 45.9, p < 0.01) with a higher proportion of men (23.4 vs. 12.4%, p < 0.01). Class III obesity group also had higher rates of comorbidities (p < 0.01). Postoperatively, class III obesity patients experienced much higher rates of wound complications (17.8 vs. 6.8%), sepsis (3.3 vs. 0.8%), venous thromboembolism (1.5 vs. 0.7%) and medical complications (6.4 vs. 1.8%), p < 0.05. Additionally, this group had higher rates of unplanned reoperation (9.2 vs. 3.7%) and 30-day readmissions (3.5 vs. 1.0%), p < 0.01. On risk-adjusted multivariate regression analyses, class III obesity was independently associated with increased risk of wound complications (OR 2.22, p < 0.01), sepsis (OR 3.53, p < 0.01), medical adverse events (OR 1.98, p < 0.05), unplanned reoperation (OR 1.62, p < 0.05) and 30-day readmission (OR 2.30, p < 0.05). CONCLUSION: Class III obesity patients are at significantly increased risk of adverse outcomes following abdominal contouring. Plastic surgeons should consider these risks for counseling and preoperative risk optimization. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand.

BACKGROUND: There is growing evidence that airway complications are relatively common in critical care. Strategies have been suggested to decrease their incidence. METHODS: We conducted a telephone survey of all adult intensive care units (ICUs) in Australia and New Zealand to establish the current practice regarding strategies used to reduce airway complications in five key areas: (i) use of capnography; (ii) care of oral tracheal tubes; (iii) care of tracheostomy tubes; (iv) difficult and failed intubation; and (v) training and medical staffing. RESULTS: Of 176 ICU meeting inclusion criteria, 171 agreed to participate. Capnography is used during tracheal intubation in 88% of ICUs and for continuous monitoring in 64%. Protocols for advancing or partially withdrawing malpositioned tracheal tubes are used by 54% of units, with most allowing repositioning by unaccredited nurses. A small minority of ICUs use bed head signs to identify patients with 'critical airways' or laryngectomy, while only 8% have specific protocols for the care of these high-risk patients. Tracheostomy emergency algorithms are available in 13% of ICUs. At night, a doctor is exclusively assigned to 73% of units, although in 72%, the night doctor is not required to have prior anaesthetic/airway training. In 97% of the institutions surveyed, the senior doctor relied upon for airway emergencies at night is either non-resident or working elsewhere in the hospital. CONCLUSIONS: Our data suggest that several possible strategies for avoiding airway complications in ICU patients dependent on an artificial airway are poorly implemented. This may expose these patients to avoidable risk.

Ethylene and hydrogen sulphide are essential for mitigating hexavalent chromium stress in two pulse crops.

Chromium toxicity to crops is a major scientific problem of the present time. Thus, scientific attempts have been made for reducing chromium toxicity to crop plants. In this study, we examined the potential of ethylene (ET, 25 µM) and hydrogen sulphide (H2 S, 10 µM) to alleviate hexavalent chromium [Cr(VI), 50 µM] stress in two pulse crops, black bean and mung bean, by assessing physiological and biochemical attributes. Cr(VI) reduced shoot and root length in black bean and mung bean in comparison to the control. Plants had increased accumulation of oxidative stress markers, i.e. superoxide radicals (SOR), hydrogen peroxide (H2 O2 ) and lipid peroxidation (as malondialdehyde, MDA). The addition of AVG (an inhibitor of ET biosynthesis) and PAG (an inhibitor of H2 S biosynthesis) to Cr(VI)-treated plants further increased Cr(VI) toxicity, suggesting their endogenous levels are important for tolerating Cr(VI) toxicity. However, supplementation with either ET or H2 S alleviated Cr(VI) toxicity. Interestingly, ET did not rescue negative effects of PAG under Cr(VI) stress but NaHS rescued negative effect of AVG. Overall, results indicate that, although both ET and H2 S alleviate Cr(VI) stress, endogenous H2 S is better. Furthermore, H2 S appears to be a downstream signal for ET in alleviating Cr(VI) stress in these two pulse crops.

Hydrogen sulphide ameliorates hexavalent chromium toxicity in two cereal crops: Role of antioxidant enzymes and proline metabolism.

Chromium pollution in soils is a major threat as it reduces crop yields. Hence, researchers seek methods/strategies which could curtail such losses. We report the role of H2 S in alleviating hexavalent chromium [Cr(VI)] stress in two cereals crops, i.e. wheat and rice seedlings, by estimating various physiological attributes. Cr(VI) reduced shoot and root length in both cereals through increased accumulation of Cr(VI) in root tips and increased in oxidative stress markers, i.e. superoxide radicals (SOR), H2 O2 and lipid peroxidation (as MDA equivalent). Supplementation with H2 S alleviated Cr(VI) toxicity in both cereal crops. Application of H2 S increased tolerance to Cr(VI) stress by protecting photosynthesis and enhancing activity of antioxidant enzymes, particularly glutathione-S-transferase and content of proline. Rice was more resistant to Cr(VI) than wheat seedlings.

A prospective, up-down sequential allocation study investigating the effectiveness of vital capacity breaths using high-flow nasal oxygenation versus a tight-fitting face mask to pre-oxygenate term pregnant women.

BACKGROUND: The role of high flow nasal oxygenation (HFNO) for pre-oxygenation before obstetric general anaesthesia remains unclear. This study aimed to determine the number of vital capacity breaths using HFNO required to pre-oxygenate 90% of parturients to an end-tidal oxygen concentration fraction (FETO2) of ≥0.90 (termed EN90). METHODS: Using up-down, sequential allocation trial design, volunteer term parturients undergoing caesarean delivery were investigated with HFNO with their mouth closed, followed by mouth open, and if FETO2 ≥0.90 was not achieved after a maximum of 20 vital capacity breaths, pre-oxygenation was attempted with a face mask. The primary outcome was the number of vital capacity breaths required using HFNO (mouth open and closed) to achieve EN90. Secondary outcomes included assessment of EN90 using mouth open versus mouth closed and face mask pre-oxygenation, maternal satisfaction and evaluation of fetal cardiotocography. RESULTS: Twenty women at term were recruited. Successful pre-oxygenation occurred in 4 (20%), 3 (15%) and 14 (70%) women with HFNO mouth closed, HFNO mouth open, and via face mask respectively. At up to 20 vital capacity breaths, face mask pre-oxygenation was more successful at achieving EN90 compared with both HFNO with a closed (P=0.006) or open (P=0.001) mouth. Closed mouth HFNO did not outperform open mouth pre-oxygenation. CONCLUSION: Face mask pre-oxygenation is more effective at achieving EN90 compared with to HFNO within a clinically acceptable number of vital capacity breaths. Further studies are needed to determine the role of HFNO in optimising the time before desaturation and for apnoeic oxygenation in term parturients.

Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future.

Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.

Long-term AAV vector gene and protein expression in mouse brain from a small pan-cellular promoter is similar to neural cell promoters.

The neurogenetic, lysosomal enzyme (LSE) deficiency diseases are characterized by storage lesions throughout the brain; therefore, gene transfer needs to provide widespread distribution of the normal enzyme. Adeno-associated virus (AAV) vectors can be effective in the brain despite limited transduction because LSEs are exported to neighboring cells (cross-correction) to reverse the metabolic deficit. The extent of correction is determined by a combination of the total amount of LSE produced by a vector and the spatial distribution of the vector within the brain. Neuron-specific promoters have been used in the brain because AAV predominantly transduces neurons. However, these promoters are large, using up a substantial amount of the limited cloning capacity of AAV vector genomes. A small promoter that is active in all cells, from the LSE beta-glucuronidase (GUSB), has been used for long-term expression in AAV vectors in the brain but the natural promoter is expressed at very low levels. The amount of LSE exported from a cell is proportional to the level of transcription, thus more active promoters would export more LSE for cross-correction, but direct comparisons have not been reported. In this study, we show that in long-term experiments (>6 months) the GUSB minimal promoter (hGBp) expresses the hGUSB enzyme in brain at similar levels as the neuron-specific enolase promoter or the promoter from the latency-associated transcript of herpes simplex virus. The hGBp minimal promoter thus may be useful for long-term expression in the central nervous system of large cDNAs, bicitronic transcription units, self-complimentary or other designs with size constraints in the AAV vector system.

Abdominal Etching: Surgical Technique and Outcomes.

BACKGROUND: The ideal body is characterized by a muscular physique and defined anterior abdominal wall. Despite diet and exercise, many are unable to achieve this desired result. Liposuction with abdominal etching is used to achieve high-definition abdominal aesthetics. The etching technique is performed with liposuction in a superficial plane, to create indentures consistent with "six-pack abs," or definition of vertical abdominal lines. METHODS: The authors' abdominal etching preoperative markings, surgical technique, and postoperative care are discussed. The surgeons' experience with abdominal etching in 50 consecutive patients is reviewed, including rate of complications and patient satisfaction. RESULTS: The average patient age was 36.4 years. We had an almost equal number of men (n = 26) and women (n = 24), with an average body mass index of 26.7 kg/m. The average blood loss was 275 ml, the average tumescence was 6 liters, and the average lipoaspirate was 5 liters. There were no major complications such as fat embolus, deep venous thrombosis, or intraabdominal injury. The most common minor postoperative complications were contour irregularities (12 percent), seromas (10 percent), and hyperpigmentation (2 percent). The majority of patients were satisfied (98 percent). The average length of postoperative follow-up was 27 months. CONCLUSIONS: Abdominal etching is a safe and effective method of creating a defined anterior abdominal wall for patients who desire the muscular definition of vertical abdominal lines. Almost all of our patients reviewed were satisfied with this procedure, maintained long-term results, and had an acceptable rate of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A global comparison of predicting equations on spirometry in the male population.

A multiple regression model considering dependent variables like vital capacity (VC), forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) and age and height as independent variables for the adult male population, which includes whites of European descent and non-whites was reviewed to evaluate the role of lung function status following standardization of age and height. Non-whites showed 0.19 litre decline in VC per decade of life as compared to 0.24 litres observed in the whites of European descent. Mean VC increased 0.05 litres per centimetre in non-whites and whites. The variation in the constant term in the regression equation determined the difference between the racial groups. Like VC, FEV1 showed ethnic differences similar to those of VC. However, the magnitude of the variation in the predicted values of FEV1 was found to be less than that observed in VC. When related to VC, FEV1 showed little difference between most European populations, New Guyanaese, Indians, Negroes, Africans and Chinese because FEV1/FVC ratio had a very narrow range between 77 and 80%.

Role of an operative score in mitral reconstruction in dominantly stenotic lesions.

OBJECTIVE: The role of an operative score in selection and results of mitral valve reconstruction in dominantly stenotic mitral lesions was assessed. METHODS: A total of 136 patients consecutively underwent reconstruction for rheumatic mitral stenosis with or without regurgitation from December 1989 through December 1994. Mitral valve structure was scored for cuspal pliability and thickness, cuspal area loss, chordal length, papillary muscle length, annular dilatation and degree of associated regurgitation and calcification. A score of 0 indicated normal valve while a score of 24 indicated a grossly deformed valve. Age, sex, functional class, cardiac rhythm, mitral valve orifice area, left ventricular and left atrial dimensions, transmitral gradients, pulmonary artery pressures and thoroughness of repair were evaluated. RESULTS: Mitral valve architecture was disorganised moderately in 50 (37%) and severely in 69 (52%) patients. Extent of thoroughness in different operative techniques correlated with good (n = 30) or adequate (n = 60) outcome. Mean mitral valve orifice area increased from 0.77 +/- 0.2 to 2.56 +/- 0.6 cm2, peak gradient dropped from 20.3 +/- 6.2 to 8.6 +/- 3.5 torr, mean gradient from 13.5 +/- 4.9 to 4.76 +/- 2.2 torr and end-diastolic gradient from 10.1 +/- 5.0 to 3.2 +/- 1.9 torr. Lack of recognition of anatomical details and of all necessary componental measures constituted the learning curve of different operators. CONCLUSIONS: Recurrent disease, learning curve, inadequate repair and higher operative mitral valve score were the factors for poorer results in the intermediate term follow-up to 64 months. Thoroughness of repair was the most important correlate of outcome and indicative of expertise.

Air monitoring network program in Saudi Arabia.

The Kingdom of Saudi Arabia has initiated a program to install air quality network stations throughout the country in order to measure concentration of the ambient air pollutants. The site selection of these stations is an important objective to be accomplished and must be done based on scientific and rational work. To accomplish this objective, a modified version of atmospheric transport and dispersion model, known as air resources laboratories - atmospheric transport and dispersion (ARL- ATAD) model, is used to evaluate long range transport and diffusion of air pollutants from major pollution causing sources such as refineries, open-air burning of associated gases of oil fields and major industries. Hourly meteorological data for a period of three years (from 1977 to 1979) on wind speed, wind direction, pressure, and temperature from 20 synoptic stations in Saudi Arabia is processed and used as model input. In addition to these, meteorological data from three upper air stations is also processed in order to determine base and top of critical inversion heights. Various pollution causing sources are identified within the study area. Air trajectories are drawn with sources as the origins of the trajectories and the dispersion characteristics is studied with distance and time. Based on long term meteorological records, the adversely affected zones are statistically identified for potential station sites.

Spirometric changes after open mitral surgery.

New York Heart Association (NYHA) functional classification of cardiac patients is assessed by subjective impairment of respiratory reserve. We objectively studied pulmonary function by spirometry in 31 random patients (average age 27.2 years) with rheumatic mitral valve (MV) disease undergoing open surgery (7 reconstruction, 24 replacement) preoperatively, predischarge and at 3 month follow-up. Better preoperative spirometric parameters were observed in class II nonsmoker patients with smaller cardiothoracic ratio (CTR) and normal pulmonary artery pressure (PAP). After surgery mean PAP decreased to 19.0 +/- 6.7 mmHg, MV gradient dropped to 3.4 +/- 2.9 mmHg, average CTR decreased to 52.3 /- 5.5%. MV area increased significantly from 0.8 +/= 0.49 to 2.45 +/- 1.23 cm2. Forced vital capacity (FVC), forced expiratory volume in one second FEV1), flow rates at 25%-75% of expired vital capacity (FEF 25-75%) and maximum voluntary ventilation (MVV) decreased significantly in all patients at discharge. Prolonged postoperative ventilatory support over 10 hours led to markedly reduced predischarge FVC, FEV1, FEF50, MVV and maximum mid expiratory flow rate (MMEFR). Prolonged cardiopulmonary bypass over 80 minutes caused further decrease in FVC. After 3 months all these parameters improved in all above the preoperative level but remained below the predicted values. Despite improvement in NYHA class, impaired spirometry was observed in 11 patients. Functional or hemodynamic improvement did not correlate with spirometric changes.

Risk-based monitored natural attenuation--a case study.

The term "monitored natural attenuation" (MNA) refers to a reliance on natural attenuation (NA) processes for remediation through the careful monitoring of the behavior of a contaminant source in time and space domains. In recent years, policymakers are shifting to a risk-based approach where site characteristics are measured against the potential risk to human health and the environment, and site management strategies are prioritized to be commensurate with that risk. Risk-based corrective action (RBCA), a concept developed by the American Society for Testing Materials (ASTM), was the first indication of how this approach could be used in the development of remediation strategies. This paper, which links ASTM's RBCA approach with MNA, develops a systematic working methodology for a risk-based site evaluation and remediation through NA. The methodology is comprised of seven steps, with the first five steps intended to evaluate site characteristics and the feasibility of NA. If NA is effective, then the last two steps will guide the development of a long-term monitoring plan and approval for a site closure. This methodology is used to evaluate a site contaminated with oil from a pipeline spill. The case study concluded that the site has the requisite characteristics for NA, but it would take more than 80 years for attenuation of xylene and ethylbenzene, as these chemicals appear in the pure phase. If fast remediation is sought, then efforts should be made to remove the contaminant from the soil. Initially, the site posed a serious risk to both on-site and off-site receptors, but it becomes acceptable after 20 years, as the plume is diluted and drifts from its source of origin.

Respiratory symptoms and ventilatory capacity in metal polishers.

To evaluate the long-term effects of metal dusts on the bronchopulmonary system and the synergistic effect of cigarette smoke, a comparative study of spirometric measurements in 104 polishers and 90 unexposed controls was carried out in 25 brass and steelware polishing industries at Moradabad in northern India. The two groups were comparable in terms of age, height, smoking habit and socio-economic status. A total of 58.6% of the polishers had one or more respiratory symptoms, compared to only 25.5% of the controls (P < 0.05). Chronic cough was present in 21 polishers (20.2%) as compared to 11.1% of the controls. However, this difference was insignificant. Chronic phlegm was nearly three times as frequent among the polishers as among the controls (17.5% vs 4.4%) (P < 0.005). The prevalence of dyspnoea of varying grades was also significantly higher (16.3% as opposed to 4.4%) among the exposed groups. Chronic bronchitis (6.7%) and occupational asthma (4.8%) were found to be confined to polishers. The polishers also experienced acute respiratory symptoms during the work shift. The prevalence of acute respiratory symptoms was recorded for cough in 19 workers (44.1%) followed by dyspnoea in 14 workers (32.5%) and throat irritation in 11 workers (25.5%). Comparison of the mean values of pulmonary function parameters in the polishers and the controls showed significant differences in the smoking and non-smoking groups (P < 0.001). The polishers exhibited significantly greater acute reductions in various lung functions over the work shift, particularly for forced expiratory flow over the 25-75% portion of the spirogram (FEF25-75%) FEF25% and FEF50%, than did the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumoconiosis risk assessment in agate workers--multiple logistic model.

A multivariate logistic model for measuring and comparing pneumoconiosis risk is described. In the first stage variables are screened on the basis of contributed variability via Pearson Chi Square statistic. Age, dust years and pack years so chosen as explanatory variables are fitted in the above model. The coefficients are estimated as linear discriminant function co-efficient. The model gives quite a good fit between observed and expected frequencies. Dust years discriminate maximum between the normal and pneumoconiosis group. Nearly sixty per cent of the variation is explained by these variables.